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Authorization Agreement Form For Electronic Funds Transfer EFT-1 - Indiana
| Authorization Agreement Form For Electronic Funds Transfer Form. This is a Indiana form and can be used in Electronic Filing Department Of Revenue Statewide . |
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StateForm50110 (R8/11-12) EFT-1 Authorization Agreement Form ForElectronicFundsTransfer Date:______________ IndianaDepartmentofRevenue IndianaTaxpayerIDNumber:___________________________ (Must Be 13 Digits)SeeSpecialInstructionsonBack. BusinessName: __________________________________________________________________________ NameandTelephoneNumberofIndividualinyourOrganizationthatRevenuemaycontactregardingEFT ContactPerson: Address: (NotaBankcontact) ____________________________________________ (Pleaseprint) ____________________________________________ oEFTRequired oVoluntary or City,State,ZIPCode: ____________________________________________ TelephoneNumber: ____________________________________________ Please complete a separate form for each tax type selected. o Sales(RST) o TireFee(TIF) o Withholding(WTH) o CorporateIncome(COR) o TypeIIGaming(TTG) o FinancialInstitution(FIT) o UtilityReceiptsTax(URT) o GasolineDistributors(MFT) o SpecialFuelTax(SFT) o StreamlinedSalesTax(SST) Please choose an EFT method. If you choose ACH Debit, you must also complete the banking information portion of this form, and attach a copy of a voided check to verify the banking information. o ACHCredit DonotusethisformtoregisterforINtax.Visit www.intax.in.gov WillthefundsfortheACHDebitpaymentscome fromabankoutsideoftheUnitedStates? o ACHDebit*(Completebankinformation) BankABANumber:_____________________ (TransitRoutingNumber) or o Checking o Savings oNooYes YourAccountNumber:___________________ (Withtheabovebank) Ifyes,theEFTSectionwillcontactyou. _________________________________________ Authorized Signature ___________________ Title ______________ Date *IfACHDebitischosen,thetaxpayerherebyauthorizestheIndianaDepartmentofRevenuetopresentdebitentries intothebankaccountreferencedaboveasrequiredbyIndianaLaw.ThesedebitswillpertainonlytoElectronicFunds Transferpaymentsthatthetaxpayerhasinitiated. This form may be faxed or mailed. Fax # .................(317) 232-1851 Questions? .......(317) 232-5500 EFT Section, Room N248, MS 103 Indiana Department of Revenue 100 N. Senate Ave Indianapolis, IN 46204-2253 American LegalNet, Inc. www.FormsWorkFlow.com Completing the EFT-1 (Authorization Agreement) Indiana TID Number - Enteryour13-digitIndianaTIDNumber.YourIndianaTIDNumberisnotyourfederal IDNumber,withtheexceptionofcorporateincome,financialinstitution,andutilityreceiptstaxes. TaxpayersregisteringforEFTtoremitcorporateincome,financialinstitution,orutilityreceiptstaxesmustusetheir nine-digitfederalIDNumberplusfouradditionaldigitsattheendasassignedbythedepartment.Ifyoudonotknowthe lastfourdigits,contacttheEFTSectionat(317)232-5500oronlyenterthenine-digitnumberandthedepartmentwill providethefouradditionaldigitsrequiredforEFTpaymentsonyourconfirmationletter. Othertaxtypesmustusea13-digitnumberasassignedbythedepartment.TaxpayersregisteringforEFTtoremit retailsales/usetax,employers'withholdingtax,orprepaidsalestaxongasolinecanfindthe13-digitnumberby referringtotheaccountnumberprintedontheirtaxpaymentcoupons,minusthefinal(14th)digit. Streamlined Sales Tax EFT ID Numbers-TheEFTTaxpayerIdentificationforStreamlinedSalesTaxistheStreamlined SalesaccountnumberassignedduringtheStreamlinedSalesregistration.TheStreamlinedSalesidentificationnumber shouldbealignedtotheleftofthefield;therefore,thenumberwouldbeS99999999.Thecertifiedserviceprovider's (CSP's)identificationnumbercanbeusedinthefuturewhenIndianaacceptsthebulkpaymentfromcertifiedservice providers.TheidentificationnumberwouldbeformattedasCSP999999. Tax Type-PleasecompleteandsubmitaseparateEFT-1formforeachtaxtypeforwhichyouareregisteringforEFT. Bank Information-ThissectionneedstobecompletedonlybythosetaxpayersselectingtheACHDebitmethod.You mustindicatewhethertheaccountischeckingorsavings.TheABA/Transitroutingnumbermustbeninedigits.Note: Youcannothavemultipleaccountsforasingletaxpayment.Pleaseverifytheaccuracyofthebankinformationentered. Taxpayer Contact-Enterthenameandcompleteaddressofthepersonwhoshouldbecontactedwithinformation concerningEFTtaxpaymentsorregardingproblemswithEFTpayments.Donotenterthenameofsomeoneatyour bank.Thedepartmentmusthaveataxpayercontact.Taxserviceprovidersmayentertheircontactinformationifthey havepowerofattorneytorepresentthetaxpayer.Acontacttelephonenumbermustalsobeprovided. Required or Voluntary-AreyouregisteringforEFTbecauseyouarerequiredbylaw,orareyouavoluntaryparticipant intheEFTprogram? Bank Outside the U.S.?-TocomplywithnewInternationalACHTransaction(IAT)rulesfromNACHA,thedepartment mustprovideadditionalinformationwithACHtransactionsgoingintoorfromabankoutsidetheUnitedStates.Ifyou answeredyestothefundsquestion,thedepartmentwillcontactyoutoobtainadditionalinformation. American LegalNet, Inc. www.FormsWorkFlow.com
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